Diagnosing erosion and supporting your patient’s behavior change

A recent survey of US and Canadian dental schools found that only 15.3% of student respondents were able to correctly identify all the clinical signs of dental erosion. This challenge extends into clinical practice, with only 30.5% of US dentists able to pass the same test. With global prevalence of dental erosion increasingly high (albeit difficult to gauge due to lack of standardization in study designs), accurate diagnosis of this condition and appropriate management can have a positive impact on your patients’ oral health and quality of life. In this article, we discuss diagnostic challenges and best practices to support your patients with dental erosion.

Understanding dental erosion

Dental erosion, often referred to as erosive tooth wear, refers to the loss of dental hard tissue due to chronic exposure to acids of nonbacterial origin (distinct from dental caries, which is mediated by acid produced by bacterial metabolism of fermentable carbohydrates). The acid involved in erosion can be intrinsic or extrinsic. Intrinsic acid present in the oral cavity consists of gastric acid originating from the stomach and entering the oral cavity, typically associated with:

• Gastro-esophageal reflux disorder (GERD)
• Eating disorders that involve vomiting, like bulimia nervosa
• Obesity
• Pregnancy, with frequent vomiting over an extended period of time
• Alcoholism.

Extrinsic acids are those from outside of the body, such as:

• A diet high in acidic foods and drinks like citrus fruits, grapes, sports drinks, soda, pickles, coffee and wine.
• Swimming frequently in Improperly treated swimming pools resulting in low-pH pool water
• Certain medications.

On exposure to intrinsic or extrinsic acids, the pH of the oral cavity is lowered and if sufficiently acidic causes loss of minerals, including calcium, fluoride and phosphate from the enamel. This demineralization process weakens the enamel.

In a healthy mouth, saliva supports buffering, helping to neutralize the intraoral pH and to restore mineral content to the teeth. Oral hygiene products containing fluoride also support the remineralization and strengthening process. However, when the buffering capacity of saliva is exceeded by chronic acid exposure, e.g., frequent acidic drink consumption, a progressive loss of minerals occurs.

Salivary flow and buffering capacity can also be impaired due to xerostomia (dry mouth). This can happen as a result of dehydration (in which case it is temporary) and/or salivary gland dysfunction, arising from auto-immune diseases (in particular Sjogren's Syndrome), prescription medication use, head and neck radiation to treat malignancies, and chemotherapy. Recreational drug use is also associated with dental erosion.

Toothbrushing before acid exposure removes the protective pellicle over the tooth, making the enamel even more vulnerable to acid attacks. On the other hand, toothbrushing shortly after an acid attack, when the enamel is in a demineralized, weakened state, leaves the enamel vulnerable to abrasion. The risk increases with the use of excessive force, a hard-bristled toothbrush, and/or a highly abrasive toothpaste.

The importance – and challenges -- of diagnosing erosion

With early diagnosis of erosion, the dental professional can intervene to help prevent further enamel and dentin loss. However, diagnosing early-stage erosion can be challenging for a number of reasons.

First, early lesions are often very subtle, and can easily be mistaken for abrasive lesions or missed altogether. Second, dental erosion typically progresses at a faster pace than dental caries, but even advanced cases can be asymptomatic.

Largely asymptomatic, hard to detect, but quick to advance – it’s a perfect storm. By the time the patient does present with symptoms like dentin hypersensitivity, they may have already experienced extensive and irreversible loss of dental hard tissue.

Detecting and assessing dental erosion

In order to detect erosion as early as possible, it is important to actively screen patients for risk factors and clinical signs at each visit. Asking the patient about their oral hygiene, lifestyle and behavioral risk factors is especially important because it helps you to:

• Implement preventive measures for high-risk patients.
• Ascertain the cause(s) of lesions in patients with existing erosion.
• Plan appropriate, tailored interventions to help prevent further enamel and dentin loss.

In the recent past, there were many different indices used to grade the severity of dental erosion. This made it difficult to compare the outcomes of clinical research and reach a consensus on prevalence, diagnosis and management of dental erosion. In response, experts developed the Basic Erosive Wear Examination (BEWE) tool.

The BEWE is a simple, convenient and unified index for evaluating dental erosion. It assesses erosive lesions on every tooth and tooth surface, giving each sextant a score based on its worst-affected tooth.

0 – No erosive tooth wear. A healthy tooth features faint grooves and ridges (the perikymata).

1 – Initial loss of surface texture. The partial loss of the perikymata is the first visible sign of erosion, and may be accompanied by localized areas of shiny, glazed, or sometimes dull enamel. Other signs include rounded “dimples” and broadened fissures on the occlusal surfaces, with a length that exceeds their depth.

2 – Distinct defect with hard tissue loss of <50% of the surface area. As erosion progresses, the teeth may take on a pearly or translucent appearance. You may see areas of yellowish discoloration as dentin becomes visible through thinned enamel. You may also observe rounding of cusps and grooves on the incisal edges and molars, and a rim of intact enamel at the gingival margins.

3 – Hard tissue loss of at least 50% of the surface area. In the advanced stages of erosion, you will be able to see large, distinct areas of hard tissue loss. The occlusal surfaces may have lost their morphology, with pits and fissures appearing to be “smoothed out”. The patient may also present with attrition of the incisors, and may be experiencing dentin hypersensitivity due to exposed dentin.

These scores are added up to give a total BEWE score, which is used to assess overall severity and inform treatment.

Managing erosion and supporting your patients

All patients with dental erosion can benefit from behavioral support in the form of dietary and oral hygiene counseling. Based on the risk factors and causes you identified during screening, you can offer your patient tailored guidance to help prevent enamel and dentin loss, and in patients who already have dental erosion to help prevent further erosion. This guidance may include:

• Reducing intake of acidic foods and drinks
• Restricting acidic drinks to mealtimes, or replacing them with water or milk
• Avoiding prolonged sipping, holding or “swishing” of acidic drinks in your mouth
• If drinking acidic drinks, to use a straw to minimize contact with your teeth
• Not brushing your teeth immediately before or after consuming acidic foods or drinks
• Chewing sugar-free non-acidic gum to stimulate salivary flow
• Using a soft-bristled toothbrush
• Taking care not to brush too aggressively.

You can also recommend that your patient uses a fluoride toothpaste and/or mouth rinse to help protect and strengthen the enamel. Colgate Enamel Health Toothpaste has a unique fluoride formula to replenish natural calcium and phosphate back into weakened enamel and to build protection against dentin hypersensitivity, while Colgate PreviDent 5000 Enamel Protect Toothpaste offers a prescription-level fluoride paste to help prevent demineralization and promote remineralization and also contains 5% potassium nitrate for relief from dentin hypersensitivity. For patients with xerostomia, you might recommend a supportive mouthwash like Colgate Hydris, designed to lock in hydration for 4 hours and relieve dry mouth.

Finally, if they are not doing so already, gently encourage your patient to address underlying health risk factors like GERD or bulimia nervosa with an appropriate physician.